Subject: Specialty Quantity Limit Benlysta 3027-H P2024

Drug

BENLYSTA  (belimumab)

Policy:

I.  PROGRAM DESCRIPTION

The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. If the member’s plan allows a quantity limit exception review for the requested medication, coverage of an additional quantity may be provided up to the exception limit with prior authorization.


II.  COVERED QUANTITIES

Medication	Standard Limit	Exception Limit*	FDA-Recommended Dosing
Benlysta (belimumab) 200 mg/mL single-dose prefilled autoinjector or single-dose prefilled syringe	4 syringes per 28 days	8 syringes per 28 days	Systemic lupus erythematosus (SLE):   •   Adults: 200 mg subcutaneous injection once weekly   •   Pediatric patients (5 to less than 18 years of age)       greater than or equal to 40 kg: 200 mg once weekly   •   Pediatric patients (5 to less than 8 years of age)      15 kg to less than 40 kg: 200 mg once every 2 weeks Lupus nephritis:   •   Adults: 400 mg subcutaneous injection once weekly      for 4 doses, then 200 mg once weekly thereafter

  *Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit Quantity Exception Criteria for approval.

 

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Benlysta [package insert]. Philadelphia, PA: GlaxoSmithKline LLC; May 2024.

 

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

June 09, 2024